Cabañas Monggini

guidelines used in making consistent decisions

It is generally acknowledged that clinician decision making is essential to effective healthcare service delivery and plays a significant role in efforts to improve quality of care (1, 2). However, there is considerable disagreement regarding the quality of clinical judgment, in particular the capacity of clinicians to conform to treatment guidelines and evidence-based practices. Some investigators believe that biased judgment so compromises service delivery that transformative initiatives should attempt to minimize clinical discretion (3–6).

  • Study participants were presented with the YPSA guideline and freely consulted it as they completed a stimulus task consisting of 64 case vignettes (with fillers) that were presented in four randomized orders.
  • In Sweden the development, quality control, implementation and use of guidelines are regularly evaluated by the National Board of Health and Welfare as well as by county councils or universities on request.
  • The “living guideline” concept relies on the quick identification of clinical trial results, but there are examples of registry data flowing into the development or updating of clinical practice guidelines (OECD, 2015).
  • Increasingly since its inception in 2003, guideline development tools include the GRADE approach (Guyatt et al., 2011; Neumann et al., 2016; Khodambashi & Nytrø, 2017).
  • However, they are not first choice when deciding about the benefits of treatment recommendations.
  • Even when time is not a consideration, many clinical questions do not have any relevant studies in the literature.
  • The paper presents and tests the new incorporation standard, describes how it informs a model of evidence-based decision making, and discusses implications of the model for future research.

Ensuring that guidelines are developed based on robust consensus processes by a multidisciplinary panel can contribute to mitigating the effect of such conflicts (see, for instance, Ioannidis, 2018). The previous section touched on the variability of evidence (both in terms of demonstrated effect and strength) regarding the success of different guideline implementation strategies. In this section we look at recent insights on how the implementation of clinical guidelines can be optimized to further facilitate their contribution to good-quality care. This timeframe also reflects the recent increased attention to implementation science in healthcare in general.

Decision-Making Challenges

New developments that aim to ensure that guideline recommendations are based on best available evidence, are easily accessible to clinicians and patients, and stay up-to-date should be further explored and evaluated. Although NICE guidance is developed for the context of England and Wales, it is often used by institutions and health professionals in other countries (see below). The Scottish Intercollegiate Guidelines Network (SIGN) is part of the Evidence Directorate of Healthcare Improvement Scotland, a public body within the Scottish National Health Service. It develops and disseminates national clinical guidelines containing recommendations for effective practice based on current evidence and has established itself as one of the go-to instances for guideline best practice in Europe. In Norway the development of official national guidelines falls under the responsibility of the Directorate of Health, although professional associations produce their own guidance in parallel (central and decentralized development).

guidelines used in making consistent decisions

In contrast to Health Technology Assessment (HTA; see
Chapter 6), there is currently no discussion about centralizing the dissemination (let alone the development) of guidelines at EU level, although umbrella organizations of different professional associations produce European guidelines for their specialties. Perhaps it is time to consider such a mechanism, especially given the recent suspension of the USA-based clearinghouse that served internationally as a frequently used resource. The survey asked about three common decision types, ranging from those that are infrequent but significant in scope to smaller, routine decisions that can be delegated.

McKinsey’s original survey research

In response, it has been claimed that administrative and organizational remedies misconstrue the purpose of clinical decision making and prove ineffective (7–9). The sundry perspectives are products of a long-standing controversy that will not be easily reconciled(10, 11). Beyond the methodological quality of the guideline itself, however, the issue of applicability is also of great importance (see also
Box 9.2). Heffner noted that as guidelines were rarely tested in patient care settings prior to publication (as would a drug before being approved), the quality of clinical guidelines is defined narrowly by an analysis of how closely recommendations are linked to scientific and clinical evidence (Heffner, 1998). This concern remains today, though it is now more explicitly addressed (see, for example, Steel et al., 2014; Li et al., 2018), raising the question of whether guidelines should be systematically pilot-tested in care delivery settings before being finalized. Furthermore, local contextual considerations often influence how guideline recommendations can be used.

guidelines used in making consistent decisions

Observational data is necessary to describe current health provision (and its quality), pinpoint potential patient groups that are adequately covered by guideline recommendations, and identify gaps and issues to be resolved by clinical research. They are also vital for identifying decision making framework late onset treatment harms and drug safety issues. However, they are not first choice when deciding about the benefits of treatment recommendations. A review of NICE guidance found that the uptake of such data in guidelines was slow (Oyinlola, Campbell & Kousoulis, 2016).

3.1. Extent of formalization of guidelines

It is known that important barriers for guideline implementation rest with lack of awareness (Cabana et al., 1999) and the reluctance of physicians to change their approach to the management of disease (Michie & Johnston, 2004). A public survey on NICE guidelines discovered that awareness of a guideline did not necessarily imply that respondents understood or knew how to use it (McFarlane et al., 2012). A related study carried out in the German primary care context found awareness of clinical guidelines to be relatively low and the inclination to treat according to guidelines not to be higher – and occasionally even lower – in those practitioners who were aware of their existence compared to those who were not (Karbach et al., 2011). Similarly, a study in the French primary care context concluded that, while a favourable disposition towards guidelines in general meant a higher likelihood of awareness of specific guidelines, it did not have a significant effect on the actual application of guideline recommendations in practice (Clerc et al., 2011).